9
Time Frames Patients were very accurate in when they expected death to occur Chemo nurses closely tracked the patients’ estimates Oncologists were off by months, usually estimating many months of survival in patients that were close to death

10
Time Frames Take home message: if an oncologist tells you that you have months to live, you’ll probably be dead in a week

11
Time Frames Patients do not expect: “5:34 PM on July 21” People want: “a few months” “a few weeks” “days” “hours”

12
Time Frames As physicians and oncologists, if we’ve taken care of enough patients, we know in our gut, with our clinical instinct, where a patient is in their trajectory People want to know to be able to plan Maybe they want to live the next month in Tuscany or Provence instead of wretching in your chemo room

13
Why is this Difficult? Social factors Our society values youth, health, wealth Elderly, sick and poor are marginalized Sick and dying have less social value

16
Why is this Difficult? Fear of therapeutic failure Medical system reinforces idea that poor outcome and death are failures of ‘system’ and by extension, our failure “all disease is fixable” “better living through chemistry” We are trained to feel this way; “if only……”

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Why is this Difficult? Fear of medico-legal system Everyone has “right” to be cured; If no cure happens, someone is to blame

18
Why is this Difficult? Fear of not knowing “we don’t do what we don’t do well” Good communication is a skill that is not highly valued, therefore not taught

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Why is this Difficult? Fear of eliciting reaction “don’t do anything unless you know what to do if it goes wrong” Not trained to handle reactions Not trained to allow emotion to come out

20
Why is this Difficult? Fear of saying “I don’t know” We are never rewarded for lack of knowledge Can’t know or control everything

21
Why is this Difficult? Fear of expressing emotions Viewed as unprofessional Suppressing emotions increases distance between ourselves and patients

22
Why is this Difficult? Ambiguity of “I’m sorry” Two meanings “I’m sorry for you” “I’m sorry I did this” Easily misinterpreted

23
Why is this Difficult? Fear of one’s own illness and death Cannot be honest with the dying unless you accept you will die

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Respond to feelings In the face of true conflict: act, don’t react If you cannot change behavior, get help

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Planning follow-through Have plan of action Make certain patient’s understand what is fixable and what is not Always be honest Patient leaves with contract: what will happen, who to call, how to call, when to return

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You have one chance to get this conversation right Patient/family will remember this always How do you want to be remembered?